Physical Outcomes of Patients With Burn Injuries—A 12 Month Follow-Up:

Assessment of health-related quality of life in patients with burns injuries during the COVID-19 epidemic: A critical topic for burn survivors

PURPOSE

It is well known that the coronavirus disease 19 (COVID-19) epidemic had an adverse effect on the health-related quality of life (HRQOL) of patients with disabilities, or neurological or chronic conditions. The aim of this study was to examine the possible factors affecting HRQOL in patients with burn injuries during COVID-19 epidemic.

METHODS

The study included a total of 40 burns patients. The demographic and burn injury information of the patients were recorded. The active range of motion was measured with a goniometer. The HRQOL, community integration, scar tissue quality and anxiety level were evaluated using the Burn-Specific Health Scale (BSHS), the Community Integration Questionnaire Revised (CIQ-R), Patient and Observer Scar Assessment Scale, and the State-Trait Anxiety Inventory, respectively.

RESULTS

The history of COVID-19 infection, total burn surface area (TBSA), community integration level, work-related burns, the presence of trunk burn injury, the presence of face burn injury, and the presence of a major burn injury were determined to be significantly associated with the HRQOL of burns patients (p < 0.05).

CONCLUSION

The history of COVID-19 infection, community integration level, and burn-related parameters (TBSA, localization, severity etc.) were found to be factors associated with the HRQOL during the epidemic. The history of COVID-19 and community integration level should be evaluated in addition to the burn injury parameters to improve the quality of life of burn survivors. It can be recommended that these clinical parameters should be considered when planning the treatment program during and after the epidemic.

Minority pediatric burn survivors undergo more burn operations: A single center's five-year experience

Burn injuries remain a significant source of trauma in the United States and disproportionately affect racial and ethnic minorities. Although disparities are well documented in adults, less is known regarding those in pediatric populations. To address this gap in literature, we aim to better characterize burn injuries, inpatient treatments, and post-discharge outcomes in minority pediatric burn patients. We hypothesize minority patients undergo more surgery and re-admissions than non-minority patients for burn care. This is a single institution retrospective chart review of pediatric patient admissions with burn injuries from July 1st, 2016 to July 1st, 2021. Demographics, details of injury, inpatient surgical and non-surgical care, and post-discharge outcomes were collected. Patients identifying as Hispanic/Latino, Black, and Asian were coded as minority patients. Univariate analysis was utilized. A total of 332 patients with average age of 4.9 years (SD: 4.4) and average total burn surface area (TBSA) of 8.5% (SD: 10.0) were collected. Minority patients were significantly more likely to experience accidental burn injury (p < 0.01), inhalational injury (p < 0.01), surgical management (p < 0.01), and to undergo skin graft (p < 0.01) than White patients. Minority patients were significantly more likely to undergo laser treatment after discharge (p < 0.01) than White patients. Our study shows minority pediatric patients are at risk for non-intentional burn injuries that undergo surgical management such as skin grafting and longitudinal reconstructive procedures including laser therapy more often. Short-term goals should include facilitating improved physical and psychosocial outcomes in this often-underserved patient population.

Reporting of scar outcomes in the hand and wrist; a state-of-the-art literature review

OBJECTIVES

The aim of this literature review was to synthesise and report current practice in evaluation and reporting of scar outcomes in hand and wrist clinical research.

METHODS

A systematic search from inception to 2022 was conducted using three electronic databases. English language randomized controlled trials and observational cohort studies reporting standardised scar outcome measures and/or scar symptoms, appearance, impairment, function, or mental health outcomes in patients with hand and wrist scars were included. Two independent reviewers determined study eligibility and performed data extraction of a priori identified scar outcome domains. Data analysis included descriptive statistics and identification of discordance in taxonomy.

RESULTS

Fifty-nine studies were included. Elective surgery cohorts were the most frequently included clinical population (n = 28; 47%) followed by burns (n = 16; 27%). Six different standardised scar outcome measures were reported by 25% of studies however only 7% of studies utilised a patient-reported measure. Scar symptoms were the most frequently reported outcome domain (81%); but taxonomy was incongruous, constructs lacked working definitions required for generalisability and outcome measurement was variable and unreported. Nineteen different measures of scar appearance and structure were reported by 30 (51%) of studies however only nine (23%) were patient-reported. Seven different hand function PROMs were reported by 25 (43%) studies. Person-centred domains including scar acceptability (12%), mental health impact (5%), and social participation (4%) were rarely reported.

CONCLUSIONS

This review highlights that evaluation and reporting of hand and wrist scar outcomes is not standardised, assessment methods and measures are under-reported and there is discordance in taxonomy. Evaluation is not person-centred, rather it is dependent on clinician assessment. Domains including scar acceptability, mental health, and social participation are rarely addressed. A stakeholder consensus derived hand and wrist scar core outcome measurement set will promote standardisation and underpin improvements in clinical research quality, transparency, and rigour.

Patterns and predictors of hand functional recovery following pediatric burn injuries: Prospective cohort study

PURPOSE

To describe the pattern of hand functional recovery in the first six months following the discharge of children with burn injury, and to identify the predictors affecting this recovery.

MATERIALS AND METHODS

This was a prospective, comparative, follow-up cohort study in which hand functional outcome, was assessed during 9 months follow-up on 37 children with burn injuries involving the upper extremity with total body service area (TBSA<35%). Thirty-six matched healthy children were participated to compare the differences between children with burn and healthy children regarding the hand functional outcome. Hand function assessments included total active motion (TAM), grip strength and Jebsen Hand Function Test (JHFT) were conducted at hospital discharge, 3, and 6 months follow-up after discharge.

RESULTS

We found a trend towards an increase in the TAM scores over time (P<0.001), and were excellent in 5.41%, at discharge and increased to 18.92% and 40.54% at 3 and 6-month following discharge. The hand grip strength and JHFT showed significant improvement over time after 6 months (P<0.001). Regression analysis revealed that time to surgery, engagement in rehabilitation services, hand dominance, age and TBSA were the predictors of hand functional recovery and accounted 74% for TAM, 0.79 and 0.86 for total JHFT scores and grip strength.

CONCLUSIONS

the TAM, grip strength and JHFT were significantly improved after 3-month and these improvements were more evident at 6-month following discharge. Identification of the predictors may help therapists in the development of an effective rehabilitation programs.

Effects of Wii Fit Rehabilitation on Lower Extremity Functional Status in Adults With Severe Burns: A Randomized Controlled Trial

OBJECTIVES

To investigate the effects of the Wii Fit rehabilitation program in addition to a standard physical therapy program (SPTP) on lower extremity functional status and functional mobility in adults with severe burns after hospital discharge.

DESIGN

A single-blinded, parallel groups, randomized controlled trial.

SETTINGS

Outpatient rehabilitation center.

PARTICIPANTS

Thirty-four patients (N=34), aged 31.3±7.3 years old, with lower extremity deep partial-thickness and full-thickness burn and total body surface area of more than 40% were allocated randomly into 2 equal groups.

INTERVENTIONS

The Wii Fit group received the Wii Fit program for 30 minutes in addition to SPTP for 60 minutes, whereas the SPTP group received SPTP only. The intervention was 3 sessions a week for 12 weeks.

MAIN OUTCOME MEASURES

The primary outcome measurements were the functional status and functional mobility, which were assessed by the high mobility assessment tool, Lower Limb Functional Index, and timed Up and Go test. The secondary outcomes included exercise capacity, muscle strength, and balance measured by the 6-minute walk test, isokinetic muscle strength assessment, and stability index. All the outcome measures were collected at the baseline and after 12 weeks of intervention.

RESULTS

After 12 weeks of intervention, there were statistically significant differences between groups in all outcome measures in favor of the Wii Fit group (P<.001). Also, statistically significant differences were found in all the measured outcomes after 12 weeks of intervention in each group (P<.05).

CONCLUSIONS

Patients with lower extremity burns who received the Wii Fit program in addition to the SPTP had better improvements in lower limb functional status, functional mobility, exercise capacity, muscle strength, and balance than patients who received SPTP alone. The Wii Fit program was a useful adjunctive therapy in rehabilitating adults with lower extremity burn injury.

Instruments to assess function or functionality in adults after a burn injury: A systematic review

INTRODUCTION

Assessment of functionality or function, through valid and reliable instruments, is essential during rehabilitation of adults after a burn injury. Currently, there is no consensus in the literature regarding the most appropriate tool that should be used to assess function or functionality; there is also no synthesis of the current studies published in this area.

OBJECTIVES

To investigate and report the instruments used to assess function or functionality in adults after a burn injury; to identify the characteristics and evidence on their measurement properties; and to evaluate their clinical utility.

METHODS

We systematically searched the literature via six electronic databases and via screening reference lists of relevant studies. The review was registered in PROSPERO (CRD42016048065) and reported according to the PRISMA statement. Studies in which function or functionality of upper and/or lower limbs of adults after a burn injury was assessed were included. Exclusion criteria comprised studies in pediatric populations and conference abstracts.

RESULTS

Thirty-four studies were included. Twelve questionnaires and seven objective tests for function or functionality were identified. Three specific tools were found; four generic instruments have been validated in burns. Nine studies evaluated the instruments' measurement properties, presenting at least one property classified as 'fair' quality. Finally, 18 instruments demonstrated clinical utility.

CONCLUSION

This systematic review demonstrated that most instruments used to assess function or functionality in adults with a burn injury have not been specifically developed for this population and had their measurement properties poorly studied. Conversely, almost all instruments had clinical utility.

The efficacy of resistance training in addition to usual care for adults with acute burn injury: A randomised controlled trial

Resistance training immediately after a burn injury has not been investigated previously. This randomised, controlled trial assessed the impact of resistance training on quality of life plus a number of physical, functional and safety outcomes in adults with a burn injury. Patients were randomly assigned to receive, in addition to standard physiotherapy, four weeks of high intensity resistance training (RTG) or sham resistance training (CG) three days per week, commenced within 72h of the burn injury. Outcome data was collected at six weeks, three and six months after burn injury. Quality of life at 6 months was the primary endpoint. Data analysis was an available cases analysis with no data imputed. Regression analyses were used for all longitudinal outcome data and between-group comparisons were used for descriptive analyses. Forty-eight patients were randomised resistance training (RTG) (n=23) or control group (CG) (n=25). The RTG demonstrated improved outcomes for the functional domain of the Burn Specific Health Scale-Brief (p=0.017) and the Quick Disability of Arm Shoulder and Hand (p<0.001). Between group differences were seen for C-reactive protein and retinol binding protein (p=0.001). Total quality of life scores, lower limb disability, muscle strength and volume were not seen to be different between groups (p>0.05). Resistance training in addition to usual rehabilitation therapy showed evidence of improving functional outcomes, particularly in upper limb burn injuries. Additionally, resistance training commenced acutely after a burn injury was not seen to be harmful to patients.

Early physiotherapy experience with a biodegradable polyurethane dermal substitute: Therapy guidelines for use

OBJECTIVE

The purpose of this study was to investigate and develop range of motion (ROM) and mobilisation guidelines in adult patients where a newly developed synthetic dermal substitute was applied in our adult burn centre.

METHOD

A retrospective case note audit was conducted on the first 20 acute burn injured patients who had a synthetic dermal substitute applied. Data collected included days to commencement of ROM, days to clearance for mobilisation, and joint ROM achieved after dermal substitute application (prior to delamination) and after split skin grafting (SSG) for the elbow, knee and shoulder joints. Scar assessments were completed at 12 months after injury using two scar assessment scales.

RESULTS

Clearance to mobilise occurred at mean 10.4 and 4.9 days after dermal substitute and after skin graft application to lower limbs respectively. ROM commenced at a mean of 9.9 (upper limbs) and 12.7 (lower limbs) days after dermal substitute application. Following skin grafting, ROM commenced at a mean of 6.6 and 6.5 days for upper limbs and lower limbs respectively. Prior to dermal substitute delamination mean flexion at the knee (86.3°), elbow (114.0°) and shoulder (143.4°) was achieved. Mean ROM continued to improve after grafting with knee (133.2°), elbow (126.1°) and shoulder (151.0°) flexion approaching normal ROM in most cases. Mean extension of the elbow (-4.6°) was maintained close to normal levels after skin grafting. There were no recorded instances of knee extension contracture. Patient and Observer Scar Assessment Scale and Matching Assessment of Photographs of Scars scores indicated good cosmetic outcomes with relatively low levels of itch and minimal pain reported at 12 months after injury.

CONCLUSION

A steep learning curve was encountered in providing therapy treatment for patients managed with this relatively new synthetic dermal substitute. Trends indicated that as experience with this new dermal substitute grew, patients progressed toward active therapy earlier. A guideline for therapy treatment has been developed but will continue to be evaluated and adjusted when required.

Six-minute walk test in burned subjects: Applicability, reproducibility and performance at hospital discharge

INTRODUCTION

Despite its clinical relevance in several populations, there is no evidence on applicability of the 6-min walk test (6MWT) in burned subjects.

OBJECTIVES

To verify the applicability and reproducibility of the 6MWT in burned individuals and to analyze patients' performance in this test at hospital discharge.

METHODS

In a cross-sectional study, burned individuals performed two 6MWT at hospital discharge, according to international standardization. In addition to walked distance, physiological and symptomatic variables were collected. Clinical history and demographic data were also recorded.

RESULTS

One hundred individuals were evaluated (70 men, 10 [6-18]% total body surface area burned). There was excellent agreement between the two 6MWT (ICC = 0.97). However, 73% of subjects increased the walked distance in the second test (23 [-9-47]m or 5 [-2-10]%; P = 0.001). Considering the best 6MWT, the walked distance was 488 [396-718]m (80 [65-92]%pred), and 51% of the individuals had limited functional exercise capacity. Additionally, participants without lower limb involvement presented better 6MWT than others (P < 0.0001).

CONCLUSION

The 6MWT was applicable, well tolerated and reproducible at hospital discharge in burned individuals. However, there was considerable learning effect between the first and second test. Finally, the reduced exercise capacity observed reinforces need for early rehabilitation in this population.

Lower limb functional status and its determinants in moderate/major burns 3-6 months following injury: A two-center observational study

INTRODUCTION

Severe complications which may cause impaired physical functionoften develops over time following severe burn to the lower extremities. The purpose of this study was to clarify the clinical determinants of lower limb functional status, functional mobility and exercise capacity in moderate/major burns 3-6 months following the injury.

METHODS

The study included 42 patients, 12 with moderate injury and 30 with major injury, aged 19-59 years old. Lower Limb Functional Index was used to determine the lower limb functional status. Functional mobility and exercise capacity were evaluated with the Timed Up and Go test and the 6-min walk test, respectively. Scar quality and kinesiophobia were assessed with the Patient and Observer Scar Assessment Scale (POSAS) and the Tampa Scale for Kinesiophobia, respectively. Active range of motion (ROM) was measured with a universal goniometer.

RESULTS

Significant and independent predictors of lower limb functional status, functional mobility and exercise capacity related to POSAS score, kinesiophobia level, gender, burn severity, the number of operations, the presence of burnsinvolving any of the lower limb joints, knee ROM limitations, limitation in any of the lower limb joint ROMs, comorbidities, and truncal burns (p < 0.05).

CONCLUSIONS

Burn characteristics and clinical evaluations of patients are important determinants of the lower limb functional status, mobility and exercise capacity in burn patients. These predictors should be considered to improve physical functions related to the lower limb when creating a personalized rehabilitation program.

Reliability testing of the Matching Assessment using Photographs of Scars App

The Matching Assessment using Photographs with Scars assessment tool, published in 2005, enables accurate relocation and reassessment of scars. While used in Australia, uptake has been hampered by its paper manual format. With electronic records and increasing use of smart devices in health, here we report the development of the Matching Assessment using Photographs with Scars manual into a mobile application format: ClinMAPS^TM Pro. At the time of development, no other digital scar assessment applications were available. For clinical validation, the digitized Matching Assessment using Photographs with Scars module within ClinMAPS^TM Pro was used for intra- and inter-rater reliability testing. Convenience sampling was utilized to recruit burns patients representing 44 scars, based on predetermined power calculations. Three therapists, one experienced and two novice, acted as the assessors. Each therapist assessed preselected scars with the digitized Matching Assessment using Photographs with Scars. Re-assessment of the same scar sites occurred 3 to 7 days later. Inter-rater reliability testing scores of the new electronic assessment application showed fair to moderate agreement (combined Fleiss Kappa = 0.38-0.49, P < .0001). Intra-rater reliability scores between initial and repeat measures showed moderate to almost perfect agreement (Cohen's Kappa = 0.43-0.90, P < .0001). It was noted that for an experienced rater, intra-rater agreement demonstrated substantial to almost perfect agreement. Intraclass correlation coefficients calculated to allow for comparison between other published scar assessment tools demonstrated excellent reliability for all scar assessment parameters for both intra- (=0.76-0.91) and inter- (=0.76-0.98) reliability. Notably, reliability testing results confirm its intra- and inter-rater reliability. Our findings validate this novel concept for digitization of the previously paper-based scar assessment manual and prove that the Matching Assessment using Photographs with Scars within the ClinMAPS^TM Pro application is now readily available for clinicians and researchers internationally.

Differential Effects of Extracorporeal Shockwave Therapy and Botulinum Toxin-A Injection on Postburn Contractures and Gait Kinematics in Burn Children

Postburn contracture is a complex and multifactorial problem that requires intensive inputs from the burn care staff. This study endeavored to evaluate the effectiveness of extracorporeal shockwave therapy and botulinum toxin-A for treating the postburn plantar flexion contracture and optimizing ankle kinematics in burn children. Thirty-eight children with burns and plantar flexion contracture were randomized to receive the standard physical rehabilitation program (control group; n = 13), unfocused extracorporeal shockwave therapy (0.2 mJ/mm2) once a week over four consecutive weeks in addition to the standard physical rehabilitation (n = 12), or botulinum toxin-A injection (0.5–2 U/kg/muscle group with maximum dose of 12 U/kg/body weight) once at entry besides the standard physical rehabilitation (n = 13). Dorsiflexion active range of motion and ankle kinematics were measured before and immediately after treatment. The posttreatment dorsiflexion active range of motion increased significantly in the extracorporeal shockwave therapy group (P = .025) and botulinum toxin-A group (P = .04) when compared to the control group. Likewise, the initial stance–dorsiflexion, stance-maximum dorsiflexion, and swing-peak dorsiflexion angle improved significantly in the extracorporeal shockwave therapy group (P ˂ .001, P = .005, and P = .002, respectively) and botulinum toxin-A group (P = .004, P = .012, and P ˂ .001, respectively) compared to the control group. No significant differences were observed between the extracorporeal shockwave therapy and botulinum toxin-A groups with respect to any of the measured variables. To conclude, extracorporeal shockwave therapy and botulinum toxin-A injection could be effectively used to treat postburn plantar flexion contracture and to optimize the ankle kinematics during walking in children, without preference for either of them.

Botulinum Toxin A for Improving Lack of Ankle Dorsiflexion Range of Motion After Major Burns-A Retrospective Chart Review

OBJECTIVE

To review the effectiveness of botulinum toxin A (BTX-A) for treating the loss of maximum ankle dorsiflexion range of motion after burn injury.

DESIGN

Retrospective chart review.

SETTING

Large urban burn center.

PARTICIPANTS

Patients (3-51 y) with major burn injury and loss of ankle dorsiflexion range while hospitalized (N=5).

INTERVENTION

BTX-A treatment in addition to standard care.

MAIN OUTCOME MEASURES

Maximum ankle dorsiflexion range of motion at time of treatment, 1 month and 3 months posttreatment.

RESULTS

Patients' total burn area ranged from 18% to 95%, and time from injury to BTX-A injection (80-125 units) was 19-93 days. Ankle range at the time of injection was -10 to -50 degrees, and all patients had improved ankle range at 1 month postinjection (-30 to +10 degrees). At 3 months postinjection, 3 participants had neutral ranges of motion that were relatively improved compared to preinjection ranges. Patients with additional complications or severe injury showed regression toward preinjection maximum ankle dorsiflexion range of motion.

CONCLUSION

This retrospective study examines BTX-A as a potential tool for treating ankle plantar flexion contractures post major burn injury after failed conservative treatment. Initial review shows some patients may benefit from these injections, but more systematically designed studies are required to assess effectiveness. If effective, further investigation will be needed to validate and standardize treatment protocols, establish dosing, and assess long-term effectiveness in those with burn injury or severe complications.

The effect of burn severity on functional capacity in patients with burn injury

BACKGROUND

Burns are traumatic injuries that result in severe tissue damage. A reduction in exercise capacity is the most common functional impairment, although it is not clear to what extent the severity of the burn injury affects the exercise capacity.

OBJECTIVE

The aim of this study was to examine the physiological responses to exercise and to evaluate exercise capacity according to burn severity.

METHODS

The study included a total of 64 burn patients, comprising 33 with moderate injuries (Total body surface area: 9.93 ± 4.73%; mean age: 37 ± 11.93 years) and 31 with major injuries (Total body surface area: 39.03 ± 10.36%; mean age: 41.09 ± 14.96 years). Heart rate, systolic blood pressure, diastolic blood pressure, double product, dyspnea level, oxygen saturation and leg fatigue before and after the shuttle walk test were recorded. Walking distances were measured after the shuttle walk test.

RESULTS

A significant difference was determined between patients with major and moderate burn injuries in respect of the cardiovascular responses to the shuttle walk test. Major burn injury patients had a significantly shorter walking distance than the moderate burn injury patients (p< 0.05).

CONCLUSIONS

Burn injury severity was seen to affect the functional capacity and cardiovascular responses to the shuttle walk test. Shuttle walk test can be preferred to evaluate moderate and major burn injury patients' functional capacity in the acute period of injury.

Health related quality of life in adults after burn injuries: A systematic review

OBJECTIVES

Measurement of health-related quality of life (HRQL) is essential to qualify the subjective burden of burns in survivors. We performed a systematic review of HRQL studies in adult burn patients to evaluate study design, instruments used, methodological quality, and recovery patterns.

METHODS

A systematic review was performed. Relevant databases were searched from the earliest record until October 2016. Studies examining HRQL in adults after burn injuries were included. Risk of bias was scored using the Quality in Prognostic Studies tool.

RESULTS

Twenty different HRQL instruments were used among the 94 included studies. The Burn Specific Health Scale-Brief (BSHS-B) (46%), the Short Form-36 (SF-36) (42%) and the EuroQol questionnaire (EQ-5D) (9%) were most often applied. Most domains, both mentally and physically orientated, were affected shortly after burns but improved over time. The lowest scores were reported for the domains 'work' and 'heat sensitivity' (BSHS-B), 'bodily pain', 'physical role limitations' (SF-36), and 'pain/discomfort' (EQ-5D) in the short-term and for 'work' and 'heat sensitivity', 'emotional functioning' (SF-36), 'physical functioning' and 'pain/discomfort' in the long-term. Risk of bias was generally low in outcome measurement and high in study attrition.

CONCLUSION

Consensus on preferred validated methodologies of HRQL measurement in burn patients would facilitate comparability across studies, resulting in improved insights in recovery patterns and better estimates of HRQL after burns. We recommend to develop a guideline on the measurement of HRQL in burns. Five domains representing a variety of topics had low scores in the long-term and require special attention in the aftermath of burns.

Demonstration of the test-retest reliability and sensitivity of the Lower Limb Functional Index-10 as a measure of functional recovery post burn injury: a cross-sectional repeated measures study design

Background

Lower limb burns can significantly delay recovery of function. Measuring lower limb functional outcomes is challenging in the unique burn patient population and necessitates the use of reliable and valid tools. The aims of this study were to examine the test-retest reliability, sensitivity, and internal consistency of Sections 1 and 3 of the Lower Limb Functional Index-10 (LLFI-10) questionnaire for measuring functional ability in patients with lower limb burns over time.

Methods

Twenty-nine adult patients who had sustained a lower limb burn injury in the previous 12 months completed the test-retest procedure of the study. In addition, the minimal detectable change (MDC) was calculated for Section 1 and 3 of the LLFI-10. Section 1 is focused on the activity limitations experienced by patients with a lower limb disorder whereas Section 3 involves patients indicating their current percentage of pre-injury duties.

Results

Section 1 of the LLFI-10 demonstrated excellent test-retest reliability (intra-class correlation coefficient (ICC) 0.98, 95 % CI 0.96–0.99) whilst Section 3 demonstrated high test-retest reliability (ICC 0.88, 95 % CI 0.79–0.94). MDC scores for Sections 1 and 3 were 1.27 points and 30.22 %, respectively. Internal consistency was demonstrated with a significant negative association (r_s = −0.83) between Sections 1 and 3 of the LLFI-10 (p < 0.001).

Conclusions

This study demonstrates that Section 1 and 3 of the LLFI-10 are reliable for measuring functional ability in patients who have sustained lower limb burns in the previous 12 months, and furthermore, Section 1 is sensitive to changes in patient function over time.

Long term outcomes data for the Burns Registry of Australia and New Zealand: Is it feasible?

BACKGROUND

Incorporating routine and standardised collection of long term outcomes following burn into burn registries would improve the capacity to quantify burn burden and evaluate care.

AIMS

To evaluate methods for collecting the long term functional and quality of life outcomes of burns patients and establish the feasibility of implementing these outcomes into a multi-centre burns registry.

METHODS

Five Burns Registry of Australia and New Zealand (BRANZ) centres participated in this prospective, longitudinal study. Patients admitted to the centres between November 2009 and November 2010 were followed-up at 1, 6, 12 and 24-months after injury using measures of burn specific health, health status, fatigue, itch and return to work. Participants in the study were compared to BRANZ registered patients at the centres over the study timeframe to identify participation bias, predictors of successful follow-up were established using a Generalised Estimating Equation model, and the completion rates by mode of administration were assessed.

RESULTS

463 patients participated in the study, representing 24% of all BRANZ admissions in the same timeframe. Compared to all BRANZ patients in the same timeframe, the median %TBSA and hospital length of stay was greater in the study participants. The follow-up rates were 63% at 1-month, 47% at 6-months; 40% at 12-months, and 21% at 24-months after injury, and there was marked variation in follow-up rates between the centres. Increasing age, greater %TBSA and opt-in centres were associated with greater follow-up. Centres which predominantly used one mode of administration experienced better follow-up rates.

CONCLUSIONS

The low participation rates, high loss to follow-up and responder bias observed indicate that greater consideration needs to be given to alternative models for follow-up, including tailoring the follow-up protocol to burn severity or type.

Towards more efficient burn care: Identifying factors associated with good quality of life post-burn

BACKGROUND

As minor burn patients constitute the vast majority of a developed nation case-mix, streamlining care for this group can promote efficiency from a service-wide perspective. This study tested the hypothesis that a predictive nomogram model that estimates likelihood of good long-term quality of life (QoL) post-burn is a valid way to optimise patient selection and risk management when applying a streamlined model of care.

METHOD

A sample of 224 burn patients managed by the Burn Service of Western Australia who provided both short and long-term outcomes was used to estimate the probability of achieving a good QoL defined as 150 out of a possible 160 points on the Burn Specific Health Scale-Brief (BSHS-B) at least six months from injury. A multivariate logistic regression analysis produced a predictive model provisioned as a nomogram for clinical application. A second, independent cohort of consecutive patients (n=106) was used to validate the predictive merit of the nomogram.

RESULTS AND DISCUSSION

Male gender (p=0.02), conservative management (p=0.03), upper limb burn (p=0.04) and high BSHS-B score within one month of burn (p<0.001) were significant predictors of good outcome at six months and beyond. A Receiver Operating Curve (ROC) analysis demonstrated excellent (90%) accuracy overall. At 80% probability of good outcome, the false positive risk was 14%. The nomogram was validated by running a second ROC analysis of the model in an independent cohort. The analysis confirmed high (86%) overall accuracy of the model, the risk of false positive was reduced to 10% at a lower (70%) probability. This affirms the stability of the nomogram model in different patient groups over time. An investigation of the effect of missing data on sample selection determined that a greater proportion of younger patients with smaller TBSA burns were excluded due to loss to follow up.

CONCLUSION

For clinicians managing comparable burn populations, the BSWA burns nomogram is an effective tool to assist the selection of patients to a streamlined care pathway with the aim of improving efficiency of service delivery.

Exercise training after burn injury: a survey of practice

Exercise programs capable of contributing positively to the long-term rehabilitation of burn patients should be included in outpatient rehabilitation programs. However, the extent and intensity of the resistance and cardiopulmonary exercise prescribed are unclear. This study was conducted to investigate the existence, design, content, and prescription of outpatient cardiopulmonary and resistance exercise programs within outpatient burn rehabilitation. A survey was designed to gather information on existing exercise programs for burn survivors and to assess the extent to which these programs are included in overall outpatient rehabilitation programs. Three hundred and twenty-seven surveys were distributed in the licensed physical and occupational therapists part of the American Burn Association Physical Therapy/Occupational Therapy Special Interest Group. One hundred and three surveys were completed. Eighty-two percent of respondents indicated that their institutions offered outpatient therapy after discharge. The frequency of therapists' contact with patients during this period varied greatly. Interestingly, 81% of therapists stated that no hospital-based cardiopulmonary endurance exercise programs were available. Patients' physical function was infrequently determined through the use of cardiopulmonary parameters (oxygen consumption and heart rate) or muscle strength. Instead, more subjective parameters such as range of motion (75%), manual muscle testing (61%), and quality of life (61%) were used. Prescription and follow-up assessment of cardiopulmonary endurance training are inconsistent among institutions, underscoring the need for greater awareness of the importance of exercise in any burn rehabilitation program. Identification of cardiopulmonary and progressive resistance parameters for establishing and tracking exercise training is also needed to maximize exercise-induced benefits.

Classification of quality of life subscales within the ICF framework in burn research: identifying overlaps and gaps

OBJECTIVE

Quality of life (QOL) is one of the leading outcomes in burn care research. This study classifies subscales of common QOL measures within the International Classification of Functioning disability and health (ICF) framework to determine to which extent the measures are complementary or overlapping and to investigate whether the instruments are able to describe the full spectrum of patients' functioning.

METHODS

A literature search was performed to determine the most frequently used questionnaires in burn research. The subscales of the three mostly used questionnaires were classified within the ICF framework.

RESULTS

Two generic measures, the Short Form-36 items (SF-36) and the European Quality of Life 5 Dimensions (EQ-5D), and a disease specific measure, the Burn Specific Health Scale-Brief (BSHS-B), were analyzed. The BSHS-B covered most domains and was the only scale that included personal factors. The SF-36 included only one domain in the activity limitations and similar to the EQ-5D no contextual factors were included. Environmental factors were not addressed in the questionnaires, even though these may have an impact on the quality of life in patients with burns.

CONCLUSION

To capture the full spectrum of dysfunctioning a combination of the BSHS-B with a generic questionnaire seems obligatory. However still some domains of functioning remain uncovered.

Enhancing the clinical utility of the burn specific health scale-brief: not just for major burns

INTRODUCTION

Like many other Western burn services, the proportion of major to minor burns managed at Royal Perth Hospital (RPH) is in the order of 1:10. The Burn Specific Health Scale-Brief (BSHS-B) is an established measure of recovery after major burn, however its performance and validity in a population with a high volume of minor burns is uncertain. Utilizing the tool across burns of all sizes would be useful in service wide clinical practice.

AIM

This study was designed to examine the reliability and validity of the BSHS-B across a sample of mostly minor burn patients.

METHOD

BSHS-B scores of patients, obtained between January 2006 and February 2013 and stored on a secure hospital database were collated and analyzed Cronbach's alpha, factor analysis, logistic regression and longitudinal regression were used to examine reliability and validity of the BSHS-B.

RESULTS

Data from 927 burn patients (2031 surveys) with a mean % total burn surface area (TBSA) of 6.7 (SD 10.0) were available for analysis. The BSHS-B demonstrated excellent reliability with a Cronbach's alpha of 0.95. First and second order factor analyses reduced the 40 item scale to four domains: Work; Affect and Relations; Physical Function; Skin Involvement, as per the established construct. TBSA, length of stay and burn surgery all predicted burn specific health in the first three months of injury (p<0.001, p<0.001, p=0.03). BSHS-B whole scale and domain scores showed significant improvement over 24 months from burn (p<0.001).

DISCUSSION

The results from this study show that the structure and performance of the BSHS-B in a burn population consisting of 90% minor burns is consistent with that demonstrated in major burns.

CONCLUSION

The BSHS-B can be employed to track and predict recovery after burns of all sizes to assist the provision of targeted burn care.

A guide to choosing a burn scar rating scale for clinical or research use

INTRODUCTION

A lack of high quality burn scar rating scales underpins the urgent need to introduce a guide for clinicians and researchers to choose the most appropriate scale for their requirements.

METHODS

An updated electronic search of Medline, CINAHL, and EMBASE databases from 2010 to 2011 of a previous published systematic review were used to identify English articles related to burn scar rating scales. The clinimetric properties, content, purpose, characteristics of the subjects tested and feasibility of each scale were critically reviewed.

RESULTS

An additional seven papers were identified by the updated search, bringing the total number of papers reviewed to 36. The majority (88%) covered items pertaining to the physical properties of the skin rated by an observer. All of the scales had been tested for the purpose of discriminating between patient groups; however, only preliminary evidence exists for the ability of the scales to measure change in scar properties over time. The majority of testing of scales occurred using Caucasian subjects, males, upper limb sites and adults.

CONCLUSIONS

This paper provides a guide to selecting the most appropriate burn scar rating scale for research and clinical practice by reviewing the content, purpose, test sample characteristics and feasibility of each scale.

Secondary burn progression decreased by erythropoietin

OBJECTIVE

To investigate whether systemic erythropoietin administration can prevent secondary burn progression in an experimental model and to elucidate the underlying mechanisms.

DESIGN

Prospective study.

SETTING

University-based laboratory research.

SUBJECTS

Twenty-one male Wistar rats.

INTERVENTIONS

The burn comb model creates four rectangular burned surfaces that are intercalated by three unburned zones (interspaces) prone to secondary necrosis. Twenty-one animals were randomized to three experimental groups: 1) Local cooling with water for 20 minutes (control, 17°C); 2) and 3) local cooling with water and intraperitoneal erythropoietin once a day for five days starting 45 minutes after burn injury (500 IU/kg body weight: EPO 500 or 2500 IU/kg body weight: EPO 2500).

MEASUREMENTS AND MAIN RESULTS

Secondary burn progression-both in depth (histology) and in surface (planimetry)-as well as interspace perfusion (laser Doppler flowmetry) and hematocrit were analyzed. Further, dilatory response (inducible nitric oxide synthase expression), inflammation (leukocyte count), and angiogenesis (CD31 expression) were assessed. Finally, wound healing time and contracture rate were reported. Burn progression resulted in complete dermal destruction as well as in important interspace necrosis in control animals, whereas burn progression was significantly reduced in a dose-dependent manner in animals treated with erythropoietin. Tissue protection was associated with an increased interspace perfusion with EPO 500, but not with EPO 2500, and was paralleled by a significant increase in inducible nitric oxide synthase expression and decreased inflammation, independent of the erythropoietin dosage. EPO 2500 led to a significant increase of hematocrit at day 4. Finally, faster wound healing and less contracture were observed in animals treated with EPO 500 only.

CONCLUSIONS

Erythropoietin represents an easy-to-use therapeutic approach to prevent secondary burn progression, i.e., to control damage after burn injury. It preserves microcirculatory perfusion within the endangered areas in a dose-dependent manner.

Validity and reliability of the FIM instrument in the inpatient burn rehabilitation population

OBJECTIVE

To provide evidence of construct validity for the FIM instrument in the inpatient rehabilitation burn population.

DESIGN

Confirmatory factor analysis and item response theory were used to assess construct validity. Confirmatory factor analysis was performed on a 2-factor model of the FIM instrument and on a 6-subfactor model. Mokken scale analysis, a nonparametric item response theory, was performed on each of the FIM instrument's 2 major factors, motor and cognitive domains. Internal consistency using Cronbach alpha and Molenaar and Sijtsma's statistic was also examined.

SETTING

Inpatient rehabilitation facilities.

PARTICIPANTS

Data from the Uniform Data System for Medical Rehabilitation for patients with an impairment code of burn injury from the years 2002 to 2011 were used for this analysis. A total of 7569 subjects were included in the study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Comparative fit index results for the confirmatory factor analyses and adherence to assumptions of the Mokken scale model.

RESULTS

Confirmatory factor analysis provided a comparative fit index of .862 for the 2-factor model and .941 for the 6-subfactor model. Mokken scale analysis showed scalability coefficients of .681 and .891 for the motor and cognitive domains, respectively. Measures of internal consistency statistic gave values of >.95 for each major domain of the FIM instrument.

CONCLUSIONS

The FIM instrument has evidence of validity and reliability as an outcome measure for patients with burn injuries in the inpatient rehabilitation setting. The 6-subfactor model provides a better fit than the 2-factor model by confirmatory factor analysis. There is evidence that the motor and cognitive domains each form valid unidimensional metrics based on nonparametric item response theory.

Rehabilitation of hand burn injuries: current updates

The improved short and long term survival rate of individuals with large burn injuries has made rehabilitation for optimal recovery of the patient increasingly important. Burn injury to the hands worsens the prospect of functional recovery and good quality of life in single events, especially when included in larger burns. The purpose of this paper is to present a narrative review of examination strategies used for children with burn injuries to the hands in the acute, intermediate and long term stages of rehabilitation, and apply these concepts to selected treatments, using a case that is representative of this complex patient population. The model of health described by the World Health Organisation provided the framework for the review, to structure the review in the domains of body structures and body functions, functional activities and participation in life roles. The lack of consensus in the burn literature regarding the most appropriate outcome measures and interventions necessitates futures research and long term outcome studies to identify, predict and prevent the difficulties patients may face over their lifespan.

Design of a cross-sectional study on physical fitness and physical activity in children and adolescents after burn injury

Background

Burn injuries have a major impact on the patient’s physical and psychological functioning. The consequences can, especially in pediatric burns, persist long after the injury. A decrease in physical fitness seems logical as people survive burn injuries after an often extensive period of decreased activity and an increased demand of proteins leading to catabolism, especially of muscle mass. However, knowledge on the possibly affected levels of physical fitness in children and adolescents after burn injury is limited and pertains only to children with major burns. The current multidimensional study aims to determine the level of physical fitness, the level of physical activity, health-related quality of life and perceived fatigue in children after a burn injury. Furthermore, interrelations between those levels will be explored, as well as associations with burn characteristics.

Methods/design

Children and adolescents in the age range of 6 up to and including 18 years are invited to participate in this cross-sectional descriptive study if they have been admitted to one of the three Dutch burn centers between 6 months and 5 years ago with a burn injury involving at least 10% of the total body surface area and/or were hospitalized ≥ 6 weeks. Physical fitness assessments will take place in a mobile exercise lab. Quantitative measures of cardiorespiratory endurance, muscular strength, body composition and flexibility will be obtained. Outcomes will be compared with Dutch reference values. Physical activity, health-related quality of life and fatigue will be assessed using accelerometry and age-specific questionnaires.

Discussion

The findings of the current study will contribute to a better understanding of the long-term consequences of burn injury in children and adolescents after burns. The results can guide rehabilitation to facilitate a timely and optimal physical recovery.

Trial registration

The study is registered in the National Academic Research and Collaborations Information System of the Netherlands (OND1348800).

Intensive exercise after thermal injury improves physical, functional, and psychological outcomes

BACKGROUND

Although exercise programs after burns are considered a standard of care, there is limited evidence for efficacy in adult patients. This study aimed to investigate the effects of an exercise program on physical, functional, and quality of life measures.

METHODS

A quasi-experimental controlled trial was instituted after final grafting. Both groups completed stretching, and the intervention group underwent a supervised high-intensity (80% maximal heart rate and 70% three repetition maximum) combined aerobic or resisted exercise program for 6 weeks, with outcome measures at baseline, 6 weeks, and 3 months by a blinded assessor. Analysis was by intention to treat.

RESULTS

Thirty patients (24 men) with a mean age of 34.3 years (± 13.1 years) and mean total body surface area 42.9% (± 13.3%) were enrolled. Inequalities at baseline (age and total body surface area %) were adjusted statistically. A between within repeated measures analysis of variance found significant group × time effects between the groups. Mean change scores from baseline to 12 weeks between control and intervention groups, respectively, were strength (kg): quadriceps (17.5 vs. 66.87), latissimus dorsi (6.07 vs. 27.82), right (4.86 vs. 14.86) and left (7.26 vs. 16.83) hand grip; fitness: peak oxygen consumption (L/min; 0.11 vs. 0.93) and shuttle walk distance (m; 168.93 vs. 459); function: lower extremity function score (8.87 vs. 27.31) and QuickDash (-5.7 vs. -23.98); and health-related quality of life: Burns-Specific Health Scale-Abbreviated (-7.64 vs. 35.13). There were no adverse events during either testing or training.

CONCLUSION

A high-intensity cardiovascular or resisted exercise program resulted in significant improvements in functional, physical, and psychologic measures and should be mandatory for all burns patients. Larger multicenter trials with longer follow-up periods are required.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Hand function measures for burn patients: a literature review

Hand function is one of the most important goals of burn rehabilitation and is a consensually important functional outcome. The purpose of this article is to review the available hand function measures commonly used for burn patients and to summarize their psychometric properties and clinical utilities to serve as guidelines for clinical practice and research. An online-database search of PubMed, MEDLINE, CINAHL and PsychInfo was performed. One hundred and seventeen articles were found and 23 of them met the inclusion and exclusion criteria. The eight identified measurement instruments were then classified into three categories: traditional component measures, performance measures and patient-reported outcome measures. Each type of hand function measure has its unique characteristics and limitations. Traditional component measures only reflect hand impairments, and may not represent hand function status. Performance measures have not been validated in the burn population and do not correlate well with patient-reported outcomes. Patient-reported outcome measures have not been rigorously validated in the burn population. A discussion of how clinicians choose these measures reflecting the purposes of their measurements and goals of intervention is provided. Moreover, future studies are suggested to develop burn-specific hand function measures.

Physiological responses to maximal exercise testing and the modified incremental shuttle walk test in adults after thermal injury: a pilot study

The ongoing hypermetabolic response associated with burn injury contributes significantly to loss of function, morbidity, and mortality. Exercise is strongly recommended to assist recovery and overall functional outcome. To date, there have been limited studies investigating the validity and practicality of both maximal laboratory and field tests in adult burns survivors. The objective of this study was to determine the metabolic and ventilatory response to cardiopulmonary maximal exercise testing (CPET) and the modified shuttle walk test (MSWT) in adult burns patients. Fifteen people (13 male) with a mean TBSA of 38.5% (16.0%) underwent both MSWT and CPET within a 5-day period in random order. The majority of participants demonstrated a normal response to CPET. Two participants with a history of inhalation burns demonstrated a respiratory limitation to exercise with desaturation (91 and 89%) at the end of the CPET, which returned to normal within 2 minutes after exercise. The correlation between VO(2peak) as measured via CPET and distance as measured in MSWT was 0.7. Mean results measured in MSWT for maximal heart rate and perceived exertion scores were lower than those achieved with CPET results: 91 and 88%, respectively. There were no adverse events during both the MSWT and CPET. This study demonstrates that after burn injury, CPET and MSWT can be performed safely in the majority of patients early in the postdischarge rehabilitation period. MSWT is likely to be submaximal at 80 to 90% of CPET results but is easy to replicate and cost-effective, thus a viable mechanism for monitoring aerobic capacity.

Physical and quality of life outcomes of patients with isolated hand burns--a prospective audit

Hand burns can have major implications on function, appearance, and quality of life. Our clinical practice has changed over the last 10 years, with a steady increase in the proportion of hand burns receiving early and aggressive surgical management using Biobrane® sheets/gloves and a concomitant fall in the proportion requiring excision and split skin grafting. The aim of this study was to measure a comprehensive range of outcomes for patients admitted with isolated hand burns to review our outcomes and provide us with the "expected" patterns of recovery. A prospective audit was performed over a 14-month period, with outcomes measured during hospital admission and at 2 weeks, 1, 3, 6, and 12 months postinjury (depending on the method of management). Outcomes comprised pain, the Burns Specific Health Scale (abbreviated version B), return to work/leisure, total active range of motion, grip strength, the Michigan Hand Questionnaire, and scar appearance using Matching Assessment with Photographs of Scars. A total of 52 patients (35 male, mean age 39 years) with 57 burned hands participated. Patients whose burn injuries were such that they were able to be managed conservatively or with Biobrane® showed rapid recovery in all outcomes, with normal or near-normal values achieved within 2 weeks to 1 month postinjury. The patients whose burn injuries required excision and split skin grafting demonstrated more marked initial deterioration, a slower rate of improvement, but eventual good recovery. In conclusion, for this sample of patients with isolated hand burns, recovery was good and rapid for those whose burn injuries were such that they were managed conservatively or with Biobrane®.

A test case: does the availability of visual feedback impact grip strength scores when using a digital dynamometer?

A cross-sectional, quantitative study of clinical measurement utility. New technological advances can challenge the efficacy of even the most widely accepted and respected tests. For example, grip strength instruments offer digital or computerized displays, precision scoring, and varied interfaces that differ from traditional Jamar™ dynamometers (Lafayette, IN). This test case explores how the opportunity to view grip strength scores during testing can influence outcomes. One hundred forty-six healthy subjects, aged 18-24 years, were tested for grip strength under visual feedback and no visual feedback conditions, using the JTech Grip Dynamometer (Salt Lake City, UT). Participants achieved a small, yet statistically significant, 1.74 lb stronger grip score with visual feedback (p<0.002). The order of grip testing conditions yielded no statistically significant differences (p=0.559). These findings suggest the need to consider how new features, unavailable with the analog Jamar™ dynamometer and unaccounted for in existing clinical guidelines could potentially influence grip scores.

LEVEL OF EVIDENCE

Not applicable.

A systematic review of the quality of burn scar rating scales for clinical and research use

INTRODUCTION

Scar rating scales have the potential to contribute to better evaluation of scar properties in both research and clinical settings. Despite a large number of scars assessment scales being available, there is limited information regarding the clinimetric properties of many of these scales. The purpose of the review was to inform clinical and research practice by determining the quality and appropriateness of existing scales. This review summarises the available evidence for the clinimetric properties of reliability, validity (including responsiveness), interpretability and feasibility of existing scales.

METHODS

Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1990 onwards were used to identify English articles related to burn scar assessment scales. Scales were critically reviewed for clinimetric properties that were reported in, but not necessarily the focus of studies.

RESULTS

A total of 29 studies provided data for 18 different scar rating scales. Most scar rating scales assessed vascularity, pliability, height and thickness. Some scales contained additional items such as itch. Only the Patient and Observer Scar Assessment Scale (POSAS) received a high quality rating but only in the area of reliability for total scores and the subscale vascularity. The Vancouver Scar Scale (VSS) received indeterminate ratings for construct validity, reliability and responsiveness. Where evidence was available, all other criteria for the POSAS, VSS and the remaining 17 scales received an indeterminate rating due to methodological issues, or a low quality rating. Poorly defined hypotheses limited the ability to give a high quality rating to data pertaining to construct validity, responsiveness and interpretability. No scale had empirical testing of content validity and no scale was of sufficient quality to consider criterion validity.

CONCLUSIONS

The POSAS, with high quality reliability but indeterminate validity, was considered to be superior in performance based on existing evidence. The VSS had the most thorough review of clnimetrics although available data received indeterminate quality ratings. On the basis of the evidence, the use of total scores has not been supported, nor has the measurement of pigmentation using a categorical scale.

A small-area population analysis of socioeconomic status and incidence of severe burn/fire-related injury in British Columbia, Canada

Socioeconomic determinants of injury have been associated with risk of burn in the UK and USA, but the relative significance of this impact is largely unknown across Canadian populations. The purpose of this study is to determine the extent to which socioeconomic status (SES) is linked to risk of burn in the province of British Columbia (BC) and identify the extent to which these findings are generalizable across both urban and rural population groups. Measures of SES were based on province-wide comparisons using data obtained from the Canada Census using the Vancouver Area Neighbourhood Deprivation Index (VANDIX). Results illustrate that the effects of SES and increased injury risk are substantial, though the most pronounced variations were exhibited across each SES stratum for urban areas and with less demonstrable effect when itemized by injury type within rural areas. Although conservative, the results from this study illustrate that burns disproportionately affect populations of greater relative socioeconomic disadvantage and continued efforts to also address social inequities and their link to injury incidence is likely to be more effective than targeting individual behavior alone when trying to reduce and eliminate their occurrence.